Provider Demographics
NPI:1467899823
Name:TUCKER, GARY EDWIN (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:EDWIN
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 WINDWARD PT
Mailing Address - Street 2:
Mailing Address - City:DISCOVERY BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94505-9510
Mailing Address - Country:US
Mailing Address - Phone:925-634-6111
Mailing Address - Fax:
Practice Address - Street 1:2489 DISCOVERY BAY BLVD STE 400
Practice Address - Street 2:
Practice Address - City:DISCOVERY BAY
Practice Address - State:CA
Practice Address - Zip Code:94505-1008
Practice Address - Country:US
Practice Address - Phone:925-634-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-25
Last Update Date:2013-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA228541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice